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6/20/2011

The DSM: more like the Boy Scout Handbook than the Bible

The Diagnostic and Statistical Manual is being revised. Often described as the psychiatric bible, there are plans for the DSM to be released in a 5th Edition. It is a work in progress.

Naturally, people ask: "if it's like a bible, why would it need to be revised?" And then they wonder: "Am I suddenly going to be cured or suddenly declared mentally ill?"

Years ago, psychiatry declared that no one was neurotic anymore. For the DSM-5, they are planning to eliminate any reference to hysteria, which means they will finally get Freud completely out of the consulting room.

Do you tend to get angry and upset, more so than most people? Then you might soon be suffering from "temper dysregulation disorder." If your kid is troubled or disturbed, there will be a new label for that, something other than the catch-all phrase, "bipolar." If you lose interest in sex and can't get started, there is a diagnosis for that too.

People in the professions argue about whether and how the DSM should be revised.

There is a concern that if any changes are made, it will suggest that they didn't get the science correct the last time around. That uncertainty could cast doubt on the entire psychiatric enterprise. Psychiatry has gotten it wrong before, most famously when it classified homosexuality as a mental illness just waiting for a cure. This adding and deleting of disorders will be the part of the argument that will get the most attention in the press.

For psychiatry, there is no end of critics. For the field in general, there is no end to the "alternative theories." The alternative "paths" to health and understanding range from the plausible to the fantastic. The fear is that change could sow doubt and confusion.

There is also a concern about the fact that the DSM is meant to represent consensus judgment. In other words, it is being done "by committee." That would perhaps be OK if everyone agreed, like in the way that everyone agrees about the symptoms of a cold or a heart attack.

In the case of the DSM-5, there is deep disagreement at a number of levels, including at the level of basic measurement. Part of the argument has to do with whether or not we are looking at categories of disturbance (like pigeonholes) or dimensions of pathology, with each person's troubles being made up of different, individual elements.

The stakes in this process are high.

The last time the DSM was revised, the committee said that kids could catch bipolar too, just like adults. In response, there are now many more "bipolar" kids taking medications. All drugs that alter mood or mind have risks, and those risks can be hard to judge in the case of a growing brain and a developing mind.

Yes, some kids need medications. But medications have become too handy as the cure for everything. That is a risk factor in itself, especially when it results in a failure to also seek psychotherapy. No child on meds should be without a therapist, period.

Lurking in the background of the DSM revision process is the pharmaceutical industry. Markets may open or close for them. Messages may need to be changed. They do sell drugs, don't they? Suspicions about profit motives have already infected the debate about how we diagnose.

To those in the intellectual leadership of psychiatry, a branch of medicine, the stakes have to do with the very definition of mental life.

NIMH (the National Institute of Mental Health) is intent on defining everything mental, emotional, and behavioral as "clinical neuroscience," like a collection of circuits and chips in our brains. From the definition of human psychology, the goal is to remove thoughts and ideas, attitudes and perceptions, and learning and development. Actually, the goal is to explain the psychological in terms of the biological hardware.

This movement began in earnest in the 1990's, a period that was officially dubbed the "Decade of the Brain." Many believed that the focus on the brain was leading to a mindless psychiatry. That is perhaps the key problem presented for psychiatry in formulating a new diagnostic manual. There is absolutely no way to get the science of mental life correct if the first step is to eliminate reference to the mental. It's not just neuroscience. It's also psychology.

In considering the controversy surrounding the diagnostic changes, we really have to ask: what is the purpose of the manual?

There is in fact a need for complex, rigorous, narrow and detailed criteria for research purposes. But in clinical work, the goal of understanding and describing the individual is often better accomplished by broader categories, unique qualifiers and unique symptom descriptions. In clinical work, the ultimate objective is to arrive at a diagnostic formulation that fits the individual patient and that provides a way to plan for treatment. You want to understand and describe the person, not the pigeonhole.

In the end, I expect that the DSM-5 will be a useful guide. I think it will be like the Boy Scout Handbook.

It will not be written in stone and it will not tell you what do in every unique and specific situation. It will guide us through many diagnostic dilemmas and it will provide fundamental data about how those people have come to be troubled and how they are having difficulties in life.

One of the things I remember best from my Boy Scout Handbook was how to treat a snake bite. They wanted you to sterilize a knife, apply a tourniquet, cut open the victim and use the snake bite suction cup from your snake bite first aid kit to suck out the poisonous venom.

That advice has long since changed, and for good reason. It was like field surgery.